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1 Changes in Family Health Insurance Coverage for Small and Large Firm Workers and Dependents: Evidence from 1995 to 2005 by Eric E. Seiber Curtis S. Florence Columbus, OH for Under contract no. SBAHQ-06-M-0513 Release Date: March 2008 This report was developed under a contract with the Small Business Administration, Office of Advocacy, and contains information and analysis that was reviewed and edited by officials of the Office of Advocacy. However, the final conclusions of the report do not necessarily reflect the views of the Office of Advocacy.

2 Created by Congress in 1976, the Office of Advocacy of the U.S. Small Business Administration (SBA) is an independent voice for small business within the federal government. Appointed by the President and confirmed by the U.S. Senate, the Chief Counsel for Advocacy directs the office. The Chief Counsel advances the views, concerns, and interests of small businesses before Congress, the White House, federal agencies, federal courts, and state policymakers. Economic research, policy analysis, and small business outreach help identify issues of concern. Regional advocates and an office in Washington, DC, support the Chief Counsel s efforts. For more information on the Office of Advocacy, visit or call (202) Receive notices of new Office of Advocacy information by signing up on Advocacy s listserves at ADVOCACY NEWSLETTER ADVOCACY PRESS ADVOCACY REGULATORY NEWS ADVOCACY RESEARCH 2

3 March 2008 No. 321 Changes in Family Health Insurance Coverage for Small and Large Firm Workers and Dependents: Evidence from 1995 to 2005 by Eric E. Seiber, and Curtis S. Florence, 2007 [64] pages. Columbus, OH Under contract number SBAHQ-06-M-0513 Introduction Access to and affordability of health insurance offered by business owners to employees continue to be of great concern. According to the National Federation of Independent Business, the cost of employer-sponsored health insurance is the most pressing problem affecting the provision of health insurance for small business owners. The objective of this study is to determine whether the decline in family health insurance coverage at large firms has increased financial pressure on plans sponsored by small firms. The study addresses family health insurance coverage from the worker s perspective. Overall Findings This study finds that family health insurance coverage for workers in both small and large firms is decreasing, and that firm size plays a role in the type of dependent coverage children have. Access to coverage through a large firm as a dependent remains very important to small firm employees. Highlights Small firm workers married to large firm workers are more likely to be covered as dependents at large firms than if their spouses work at small firms. Specifically, in 2005 an estimated 47 percent of small firm workers with a spouse working in a large firm were covered as dependents, compared with 23.5 percent of small firm workers with a spouse working in a small firm. The study also finds that few large firm employees are shifting their coverage from their large firm to dependent coverage under their small firm spouse s plan. Large firm workers married to small firm workers experienced a decline in coverage from work of almost 3 percentage points compared with an increase of about 0.8 percentage point in coverage through their small firm spouses. Small firms do face more financial pressure from the decline in large firm dependent coverage of children; however, the effect is quite small, with an increase of less than one percentage point in the share of children covered as dependents by small businesses when their parents work at different-sized firms. The findings show that children are more likely to have dependent coverage if they have a parent working in a large firm. In 2005, 63.7 percent of children with both parents working at a small firm had dependent coverage, compared with 78 percent if one parent worked at a large firm and the other at a small one, and 81 percent if both parents worked at a large firm. Nonemployer coverage of children is especially important for families where both spouses work in small businesses. This "other" coverage has reduced the share of small firm worker parents with uninsured children from 16.4 percent to 11.0 percent. Over the study period 1995 to 2005, dependent coverage for married workers increased slightly for large firm workers with a spouse working in a small firm. Also, there has been an increase in dependent coverage of small firm employees by their large firm spouses, which should decrease the financial pressure on small firms. Scope and Methodology The researchers use data from the Annual March Demographic Survey of the Current Population The opinions and recommendations of the authors of this study do not necessarily reflect official policies of the U.S. Small Business Administration or other agencies of the U.S. government.

4 Survey (CPS) for 1996, 2001, and The March CPS is collected by the U.S. Census Bureau on behalf of the Bureau of Labor Statistics. From 1996 to 2001, the survey sampled approximately 60,000 households annually. The March CPS surveys are an extensive collection of information on the work experience, income, and demographics of the U.S. noninstitutionalized population, and are also primary sources of information on health insurance coverage. The CPS does not contain any information on health insurance costs. To control for differences in health insurance costs across different locations and across time, the authors use premium data from the Federal Employees Health Benefits Program (FEHBP). Therefore, FEHBP premiums can serve as a proxy for local health insurance costs. The FEHBP data were merged with the CPS data by calculating the mean FEHBP managed-care plan premium for each metropolitan statistical area (MSA) in the United States, and then matching this mean premium with each respondent s MSA code in the CPS data. Respondents who did not live in an MSA were assigned the mean premium for all of the MSAs in their state. If their state did not have an FEHBP plan, they were assigned the premium for the Blue Cross Blue Shield FEHBP plan for that year. This study uses a series of four multinomial logit models to test whether spouses working for large firms and children previously covered through large firms have shifted to dependent coverage in group plans sponsored by small businesses. For a shift in coverage from large firm to small firm employers to occur, a family must have a mix (a spouse working at a large and small firm) of workers who can potentially cover dependents through their job. For this reason, employer-based health insurance for two-earner married couples and their children is analyzed. One major limitation of this study is that the data did not make it possible to determine if workers or employers were dropping health insurance coverage. This report was peer-reviewed consistent with Advocacy s data quality guidelines. More information on this process can be obtained by contacting the director of economic research by at or by phone at (202) Ordering Information The full text of this report and summaries of other studies performed under contract with the U.S. Small Business Administration's Office of Advocacy are available on the Internet at research. Copies are available for purchase from: National Technical Information Service 5285 Port Royal Road Springfield, VA (800) or (703) TDD: (703) Order number: PB Paper A05 ($31.50) Microfiche A01 ($14.00) CD-ROM A00 ($24.00) Download A00 ($18.95) To receive notices of Advocacy's newsletter, press, regulatory news, and research, visit For really simple syndication, visit

5 Changes in Family Health Insurance Coverage for Small and Large Firm Workers and Dependents: Evidence from 1995 to 2005 by Eric E. Seiber Curtis S. Florence Columbus, OH for Under contract no. SBAHQ-06-M-0513 Release Date: March 2008 This report was developed under a contract with the Small Business Administration, Office of Advocacy, and contains information and analysis that was reviewed and edited by officials of the Office of Advocacy. However, the final conclusions of the report do not necessarily reflect the views of the Office of Advocacy. 3

8 List of Tables Table 1: Distribution of Health Insurance Coverage for Married Workers in Two-Earner Couples, By Year Table 2: Distribution of Health Insurance Coverage for Married Workers in Two-Earner Couples, By Worker and Spouse Firm Size, and Year Table 3: Descriptive Statistics for Married Adult Workers, Two-Worker Couples Table 4: Multinomial Logit Estimates of Health Insurance Coverage for Married Adult Workers in Two-Worker Couples, Relative Risk Ratios with Coverage from Own Employer as Reference Category, Model Table 5: Simulated Insurance Coverage Rates from Model 1, by Worker and Spouse Firm Size and Year Table 6: Distribution of Health Insurance Coverage for Children of Married, Two-Worker Couples (Model 2), by Year Table 7: Distribution of Health Insurance Coverage for Children of Married, Two-Worker Couples (Model 2), by Parent s Firm Size and Year Table 8: Descriptive Statistics for Children in Two-Parent (Model 2), Two-Worker Households Table 9: Multinomial Logit Results for Insurance Coverage of Children in Two-Parent, Two- Worker Households, Relative Risk Ratios with Coverage Through a Parent s Employer as the Reference Category, Model Table 10: Simulated Insurance Coverage for Children in Two-Parent, Two-Worker Families (Model 2), by Year and Firm Size of Parents Table 11: Distribution of Coverage by Large Firm Parent for Children in Married, Two-Worker Families (Model 3), by Year Table 12: Descriptive Statistics for Children in Two-Parent, Two-Worker Families, Where One Parent is a Small Firm Employee and the Other is a Large Firm Employee, Covered as Dependents in Employer-sponsored Health Insurance Plans (Model 3) Table 13: Logit Results for Probability of Being Covered by the Large Firm-Employed Parent (Model 3) Table 14: Simulated Probability of Being Covered by a Large Firm Parent for Children Covered as Dependents by an Employer Plan (One Parent Works at a Large Firm and One Parent Works at a Small Firm), by Year (Model 3) iii

9 Executive Summary Recent research has found that 38 percent of U.S. workers with health insurance coverage in 2005 had family coverage, down from 41 percent in The change was especially acute for small businesses, with the percentage of workers covered by a family plan dropping from 39 percent in 2001 to 32 percent in 2005 (KFF 2005). This study examines the Annual Demographic Survey of the Current Population Survey (CPS) to determine if the decline in health insurance coverage at large firms has increased financial pressure on plans sponsored by small firms. This study uses a series of four multinomial logit models to test whether spouses working for large firms and children previously covered through large firms have shifted to dependent coverage in group plans sponsored by small businesses. The study examines two specific study questions. First, what is the relationship between worker firm size and health insurance coverage in households with two married workers? Second, has the decline in coverage through large firms led to increased coverage of dependents by small firm workers? The study documents trends in family coverage at both small and large firms for the years 1995, 2000, and It then examines whether declines in family policies at large firms shift family members to plans sponsored by small firms. This is done by examining the two groups whose health insurance coverage can possibly be shifted between firms: twoworker married couples and their dependent children. We estimate regression models for employer health insurance coverage for policyholders and dependents to determine if these trends still hold when controlling for confounding factors that affect health insurance coverage. The study produces four primary findings. First, small firm workers who are married to large firm workers are more likely to be covered as dependents at large firms. Specifically, in 2005 the results estimate that 47 percent of small firm workers with a large firm spouse are v

10 covered as dependents. Meanwhile, only 23.5 percent of small firm workers who have a small firm spouse are covered as dependents. Our results show that access to coverage through a large firm as a dependent remains very important to small firm employees. Second, few large firm employees are shifting their coverage from their large firm plan to their small firm spouse s plan. Large firm workers who are married to small firm workers experienced a decline in coverage from work of almost 3 percentage points. However, they experienced an increase of only about 0.8 of a percentage point in coverage through their small firm spouses. Third, children are more likely to have dependent coverage if they have a large firm parent. For 2005, 63.7 percent of children with both parents working at a small firm had dependent coverage, which increased to 78 percent if one parent worked at a large firm and 81 percent if two parents did so. Access to insurance through a large firm employee greatly increases access to coverage for children, just as it does for adults. Fourth, small firms do face more financial pressure from the decline in large firm coverage of children; however, the effect is quite small an increase of less than one percentage point in the share of children covered by small businesses when their parents work at differentsized firms. The study also produced two unanticipated findings that merit more research. First, across all firm sizes, fewer workers are covered through their own employer, and they are increasingly obtaining dependent coverage through their spouse. This finding implies that workers are concentrating their insurance coverage at fewer firms. In effect, firms are shifting the costs of their workers' coverage to other firms, both large and small. We also found that nonemployer coverage of children is especially important for families where both spouses work vi

11 at small businesses. This "other" coverage has reduced the small firm parents with uninsured children from 16.4 percent to 11.0 percent. In conclusion, does the overall decline in family health insurance coverage in all firms increase pressure on small businesses? This report concludes the answer would be yes, since married workers have substituted for the loss of employer coverage with dependent coverage from a spouse. The magnitude of this pressure has remained small for the period 1995 to 2005; however, if coverage through employment continues to decline, small firms that still offer coverage will likely face increasing enrollment of dependents on their plans. vii

12 Introduction This study utilizes the Annual Demographic Survey of the Current Population Survey (CPS) to determine if the decline in health insurance coverage at large firms has increased financial pressure for dependent coverage on plans sponsored by small firms. This increased financial pressure could come from spouses at large firms who previously had their own coverage, but now are covered as a dependent on their spouse s plan, and from children who were previously covered by a parent who worked at a large firm, but are now covered by a parent at a small firm. This analysis examines the impact on small businesses from the changes in family coverage occurring at all firms. We address two specific study questions. First, what is the relationship between worker firm size and health insurance coverage in married, two-worker households? Second, has the decline in coverage through large firms led to increased coverage of dependents by small firm workers? We document trends in family coverage at both small and large firms for the years 1995, 2000, and We then examine whether there have been declines in family policies at large firms and whether these declines shift family members to plans sponsored by small firms. This is done by examining the two groups for whom health insurance coverage can be shifted between firms: adults in two-worker married couples and their dependent children. We estimate regression models for employer health insurance coverage for policyholders and dependents to determine if these trends still hold when controlling for other factors that affect health insurance coverage. Specifically, our results will examine if small firms have experienced an increase in the enrollment of dependents, and if a growing number of large firm workers are enrolling in health plans sponsored by small firms. If so, this could increase the total cost of labor in small firms.

13 We find that: Employer coverage of policyholders has declined for all workers over the study period. Dependent coverage for married workers has increased slightly over the study period for large firm workers who have a spouse working at a small firm. Dependent coverage of small firm employees by their large firm spouses has increased, which should decrease the financial pressure on small firms. Dependent coverage of children has decreased slightly over our study period, but the percentage of dependent children covered by a large firm-employed parent has remained steady. These results are confirmed by regression analysis that controls for health insurance costs, worker and local area characteristics. Literature Review Recent research has highlighted the importance for small business employees of access to family coverage through a spouse working at another firm. Abraham and Royalty (2005) use the 1996 Medical Expenditure Panel Survey to compare insurance coverage of one- and two-earner households in In households with a single wage earner, employees of small establishments were 29 percentage points less likely to be covered by an employer-sponsored plan than employees of large establishments, but the presence of a second earner in the household offsets 62 percent of the negative effect on coverage from working for a small business. However, this study did not examine the effect of the firm size of the spouse on the likelihood of coverage. Farber and Levy (2000) use supplements to six years of the Current Population Survey (CPS) to confirm the importance of coverage through a spouse, finding that 30 percent of the decline in own-employer insurance coverage between 1988 and 1997 was offset by spousal coverage. Polsky et al. (2005) found a similar effect for spousal coverage when the employee s share of the 2

14 premium contribution changes, utilizing the 1996 and 1998 rounds of the Community Tracking Study Household Survey. The continuing decline of family coverage raises particular concern given the importance of this type of insurance in extending coverage to employees of small businesses. In their 2005 Survey of Employer Health Benefits, the Kaiser Family Foundation and the Health Research and Educational Trust reported that family coverage in the United States has declined from 41 percent of covered workers in 2001 to 38 percent in The change was especially acute for small businesses, with the percent of workers covered by a family plan dropping from 39 percent in 2001 to 32 percent in Contributing to this decline in family coverage has been the large increase in premiums for these family plans, 71.3 percent from 1996 to 2005 for small firms and 57.7 percent for large firms. Although the literature establishes the importance of coverage through a spouse for small business employees, no study examines the relationship between coverage and the firm size of the spouse, or how the continued decline in family coverage has affected small businesses. Furthermore, the studies highlighting the importance of access to coverage through a spouse rely upon data from the mid and late 1990s, before the most recent declines in family coverage. This study remedies these gaps in the literature by examining the relationship between the firm size of the spouse and the coverage of small firm workers, and how changes in family coverage have affected small firms over the time period. 3

15 Policy Relevance Facilitating access to health insurance through small businesses remains a high priority for federal, state, and local policy makers. On the federal level, both President Bush during the 2004 campaign and the House of Representatives have proposed subsidies for small business health insurance (New York Times 2004, Kaiser Family Foundation 2005). In the first half of 2006, the states of Oklahoma, Rhode Island, and Washington all implemented or expanded premium subsidy programs for small businesses (Kaiser Family Foundation 2006, Gurais 2006, Shannon 2006). Targeted health insurance subsidies are sufficiently popular that they have even been implemented by individual counties to promote small business development (California Healthcare Foundation 2006). Researchers differ on the potential impact of premium subsidies. These differences focus on subsidies limited potential to reduce the total number of uninsured workers in the United States and not just uninsured workers at small businesses. Reschovsky and Hadley (2001) estimated with 1997 data that a 30 percent premium subsidy for small businesses would extend coverage to only about one half million uninsured workers nationally. In the case of San Diego County in 2001, Kronick and Olsen (2006) found very few small businesses that did not offer group plans and that had many uninsured workers. For firms that did not offer insurance, 75 percent had zero or one uninsured worker. However, the highest number of uninsured was found in firms with employees that did not offer insurance. For policymakers interested in strengthening small businesses, the findings of these studies are of limited interest. These studies assess small business development policies from the perspective of their impact on the total number of uninsured in the United States, not the policies impact on the small business environment. Furthermore, these studies rely on five- and 4

16 ten-year-old data that do not capture the rapid increases in insurance premiums over that last half decade. Moreover, these studies focus on reducing the number of uninsured rather than on the health of small businesses. Hypotheses Based on the previous results in the literature and our study questions, we developed four hypotheses to test in this study. They are: Hypothesis 1: Given the importance of a working spouse in increasing the probability of health insurance coverage, and the advantages of large firms in providing such coverage, we expect small firm workers who have a spouse working at a large firm to be more likely to be covered as a dependent than small firm workers with a spouse working at a small firm. Hypothesis 2: Given a decline in large employer coverage over time, large firm workers will be less likely to be covered by their own job, and more likely to be covered as dependents by their spouses working in small or large firms. Hypothesis 3: Children will be more likely to have dependent coverage in an employer plan if they have a parent who works at a large firm. Hypothesis 4: Given a decline in large firm dependent coverage of children, a growing percentage of children will be covered as dependents by small firm workers. Data We use data from the annual March supplements of the Current Population Survey (CPS) for 1996, 2001, and i The March CPS is collected by the U.S. Census Bureau on behalf of the Bureau of Labor Statistics. From 1996 to 2001, the survey sampled approximately 60,000 5

17 households annually, which comprised approximately 120,000 total individuals. Starting in 2002, the March survey was expanded to almost 100,000 households, and comprised more than 200,000 individuals. The March CPS surveys are an extensive collection of information on the work experience, income, and demographics of the U.S. noninstitutionalized population, as well as their health insurance coverage. Data are collected on each individual who resides in a sampled household. Each March supplement asks about a person s work experience and health insurance coverage in the prior calendar year. Therefore, the data contain information on labor market experience and health insurance coverage for 1995, 2000, and ii Each individual is asked to report all types of health insurance they had in the previous year. This means that some individuals may report multiple types of coverage during the year. However, there is no information in the CPS on the duration of coverage. Since we are primarily interested in coverage from employers, we construct a mutually exclusive hierarchy of coverage, so that if a person reports having employer-sponsored coverage in their own name, they are considered to have that as their primary coverage. If they do not report coverage as a policyholder, but report coverage as a dependent, they are reported to have that as their primary coverage. If a person does not report employer-sponsored coverage, but reports some other type of coverage (public plans such as Medicaid and Medicare, and plans purchased in the private market), that is their primary coverage category. Finally, if a person does not report any coverage, they are considered uninsured, and that is the final coverage category. In addition to the health insurance variables, the CPS also contains a variable that lists the policyholder within the household for all persons with dependent coverage. This variable allows us to determine the individual in the household that is the policyholder for the employer-sponsored insurance that covers dependents. We can 6

18 therefore match the characteristics of the policyholder to all dependents in the household. In addition to the health insurance variables, the March CPS also contains information on the number of employees at all locations of a worker s main job in the previous year. We use this variable to construct an indicator for each worker that is =1 if they are employed at a firm with 500 or more workers, which we use as our criterion for a large firm. This criterion is based on the most common employee size requirement used by the Small Business Administration (SBA) to determine eligibility for SBA programs. The SBA also uses other criteria such as total revenue to determine if a firm is a small business. Since no such firm-level data are available for the participants in the March CPS, we do not use revenue as a criterion in defining a small business. Many factors in addition to firm size can affect the likelihood that a person has insurance coverage. To determine if the changes in health insurance coverage we document are related to firm size, we must also control for those variables in our analysis. We use information in the CPS on age, income, education level, family structure, industry, and occupation to control for other factors that also influence insurance coverage. Note that government is included among the industries shown (Table 3). Potentially one of the main determinants of health insurance coverage is the cost of coverage. The CPS does not contain any information on health insurance costs. To control for differences in health insurance costs across different locations and across time, we use premium data from the Federal Employees Health Benefit Plan (FEHBP) to control for differences in premiums across local markets. All local plans are allowed to participate in the FEHBP as long as their premiums are not greater than those they charge local employers of similar group size and demographics (Florence and Thorpe (2003)). Therefore, FEHBP premiums can serve as a proxy for local health insurance costs. 7

19 The FEHBP data were merged with the CPS data by calculating the mean FEHBP managed-care plan premium for each metropolitan statistical area (MSA) in the United States, and then matching this mean premium with each respondents MSA code in the CPS data. Respondents who did not live in an MSA were assigned the mean premium for all of the MSAs in their state. If their state did not have an FEHBP plan, they are assigned the premium for the Blue Cross Blue Shield FEHBP plan for that year. The specifications for all the variables used in the analysis are described in detail in the empirical section below. Detailed information on the methodology used to construct the health insurance dependency variables and the health insurance costs data can be found in the appendix. Empirical Methodology Dependents in private health insurance are typically spouses, children under 18, and children over 18 who are full-time students. For a shift in coverage from large firm to small firm employers to take place, a family must have a mix of workers who can potentially cover dependents through their job. This could occur in households where the two spouses in a married couple both work. iii For that reason, we analyze the employer-based health insurance for twoearner married couples and their children. Many factors other than firm size influence the probability of insurance coverage, including the cost of coverage, family income, and demographic factors such as education and the region of the country. Since the outcome in this case is a categorical, mutually exclusive variable where the independent variables are all characteristics of the individual, not the type of insurance coverage, the model is estimated as a multinomial logit. The multinomial logit regression model estimates the probability of having a given type of insurance coverage as a 8

20 function of the individual s characteristics. The probability of having a particular type of coverage is given as: P( y i exp( Z iγ j ) = j) = J exp( Z γ ) j= 1 i j Where: i=1,,n (where N represents the total number of adults in the analysis sample) j=1,2,3,4 y i =1 if the worker has employer health insurance in their own name y i =2 if y i 1 and if the worker is covered as a dependent on their spouse s employer plan y i =3 if y i 1 and y i 2 and if the worker has some other type of coverage y i =4 if y i 1, y i 2 and y i 3, the worker is considered uninsured A flow chart presenting the weighted distribution of these four insurance outcomes is given in Chart 1. The Z i is a matrix of the individual s characteristics, and γ j are the coefficients that give the effect of the characteristics on the likelihood of coverage. To estimate the multinomial logit model, the coefficients for one insurance category must be set to zero. In the estimation results that follow below, we choose coverage from the worker s own employer as the reference category (γ 1 =0). The estimated coefficients then represent the effect of the variable on having one of the other types of coverage relative to having coverage from the worker s own employer. 9

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